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AppT{catlons Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable,Revocable,and Suspendable) SEPTAGEE <br /> t ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application I&hereby m to c rryon busi ss in the jurisdictional area of the S Jcq Local Health District <br /> I Business Name D A) oa . 0 Address (J <br /> se- <br /> a Address <br /> Firm Partners,Addresses and Telep one Nu m�ber� <br /> a Business Telephone No. ! Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name(Print) Title Date_? ,Please¢heck Applicable Categ (1-7)and Fill in th equired Information <br /> I <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) <br /> 1 <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr.,Color) f <br /> Serial No. CAL.License No. CAL License Renewal No. V <br /> Capacity Gal.,Weights&Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No.of Vehicles Stored <br /> No. of Chemical Toilets Stored t' <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E.Name R.S.or R.C.E.NO. <br /> Test L Pcation Test Date/Time ? <br /> 4.A-SANITATION PERMIT <br /> Joddr ation <br /> VSE <br /> w 13A dress r^ <br /> SEP �ANK CESSPOOL CHING FIELD M-5EE'PAGE PIT ❑ PACKAGE PLANT <br /> 10-PERMANENT ❑ TEMPORARY q-p 4 ❑ REPAIR ❑ OTHER <br /> S. ❑ CHEMICAL TOILETS For July 1,-June 30,19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30,19 <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity No:Units Served <br /> 7. ❑ LAUNDRY For July 1.-June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq.Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> hereby certify that I have prepsis application and that the work will be done in accordance with San Joaquin County <br /> ordinances,state laws,and rul d regu tions o e San Joaquin ocai Health istrict. <br /> APPLICANT'S SIGNATURE) <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY PER UNIT Q PER SITE ❑ EACH ❑ January 1&Received By January 31 ❑ July 1&Received By JUIV 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE V <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Az A 44 <br /> Received by Date Receipt No. Permit No. ISivance to Mailetl DeilvBfed <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.14AZELTON AVE.,F.O.Boa 2009 STOCKTON,CA 95201 <br />